A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?
Numbness of fingers
Abdominal pain
Dry skin
Lethargy
The Correct Answer is D
Choice A reason: Numbness of fingers is not a sign of respiratory acidosis. It can be caused by other conditions such as peripheral neuropathy, Raynaud's syndrome, or carpal tunnel syndrome.
Choice B reason: Abdominal pain is not a sign of respiratory acidosis. It can be caused by other conditions such as gastritis, appendicitis, or gallstones.
Choice C reason: Dry skin is not a sign of respiratory acidosis. It can be caused by other conditions such as dehydration, eczema, or hypothyroidism.
Choice D reason: Lethargy is a sign of respiratory acidosis, as it indicates a low level of oxygen and a high level of carbon dioxide in the brain. Lethargy is a state of reduced mental and physical activity, which can progress to confusion, coma, or death if not treated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A reason: Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of stool in the colon. The nurse should advise the client to respond to the urge to defecate as soon as possible and to establish a regular bowel routine.
Choice B reason: Increased fiber in the diet is not a cause of constipation, but rather a prevention measure. Fiber helps to soften the stool and increase its bulk, which facilitates its passage through the colon. The nurse should encourage the client to consume adequate amounts of fiber from fruits, vegetables, whole grains, and legumes.
Choice C reason: Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependency. The nurse should instruct the client to avoid using laxatives unless prescribed by the provider and to use them only for a short period of time.
Choice D reason: Increased activity is not a cause of constipation, but rather a prevention measure. Activity helps to stimulate the peristalsis of the colon and promote bowel movements. The nurse should recommend the client to engage in moderate physical activity for at least 30 minutes a day
Correct Answer is D
Explanation
Choice A reason: Stripping the client's chest tube every 2 hours is not a recommended action, as it can cause excessive negative pressure, tissue trauma, and pain. The nurse should only strip the chest tube if there is a clot or obstruction in the tubing, and only with the provider's order.
Choice B reason: Looping the tubing of the chest tube on the client's bed is a correct action, as it prevents kinking, tension, or pulling on the chest tube. The nurse should also secure the tubing to the bed sheet with a safety pin.
Choice C reason: Placing the chest tube drainage system above the level of the client's heart is not a correct action, as it can cause the fluid to flow back into the chest cavity and impair lung expansion. The nurse should place the chest tube drainage system below the level of the client's chest.
Choice D reason: Taping the connections on the client's chest tube is a correct action, as it prevents air leaks, disconnections, or accidental removal of the chest tube. The nurse should also check the connections regularly for tightness and patency.
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